Hepatitis

Hepatitis is Latin for "inflammation of the liver". The liver does
many things in our bodies, including storing and releasing glucose
to keep your blood sugar constant as well as getting rid of many useless
and harmful chemicals including drugs, food breakdown byproducts, and
breakdown products of old blood cells. If the liver can't function,
one of the first signs is jaundice, as bilirubin (a breakdown
product of hemoglobin from old blood cells) accumulates in your body
and makes you turn yellow. Hippocrates first described jaundice in
ancient times; outbreaks of jaundice -- most likely caused by hepatitis
A -- occurred in the 1600's and 1700's, often during wars (not too
surprising, since hepatitis A is often transmitted when sanitation is
poor).

There are many things, including drugs as well as infections, that can
cause liver inflammation or malfunction. There are several viruses that
do little more than cause liver damage, but the damage they do is serious.
Fortunately we now have vaccines for the two most common hepatitis
viruses: hepatitis A and hepatitis B.

Hepatitis A is usually found in the feces (stools) of infected persons,
and is usually transmitted by something politely termed "fecal-oral
contact". This is not to say that people deliberately eat
the stools of infected persons: unfortunately, an infected person
who is careless about hygiene can carry the virus on hands and fingers --
and transfer the virus to food and drink -- and in areas with poor
sanitation the virus can sometimes be found in drinking water during an
outbreak. We don't usually see contaminated drinking water in the United
States, or in other countries with pretreated municipal water supplies,
but in some less-developed areas fecal contamination of drinking water is
a big problem. The virus can also be left on toilet seats by an infected
person, and can infect others through that route. It takes from 15 days
to 2 months after exposure to develop symptoms of hepatitis A, which start
fairly suddenly and include fever, malaise, nausea, abdominal pain, and
loss of appetite as well as the jaundice. The urine also may turn dark
because of bilirubin being filtered out of the blood and into the urine.

Hepatitis A is not very common in the United States because of our
sanitation and water-purification procedures. It appears occasionally,
though. Usually hepatitis A outbreaks happen when someone infected while
travelling transmits the virus to others. Often the "index patient"
is a food handler who deposits the virus on foods during preparation.
Another source of hepatitis A can be a particular shipment of food that
was grown in an area with contaminated water, leaving the virus on the
surface of the plant. In these cases public-health investigators find
that all the newly-infected people ate food from or at a particular place.

Since hepatitis A is still common in developing countries and is seen
frequently even in the United States, we now recommend vaccinating children
against the hepatitis A virus. Two doses given at least six months apart
appear to give lifelong protection. Children must be at least 1 year old
to develop immunity from the vaccine. Immune globulin from previously
infected persons can be given to those who are not immune and who have been
exposed to the virus or who must travel to an area where many people have
hepatitis A. The passive immunity provided by the immune globulin only
lasts for a few months.

Hepatitis B is generally transmitted by blood and body fluids. Until
we were able to test for the virus itself, hepatitis B was a common
complication of blood transfusion; nowadays every unit of blood
used for transfusion is tested for hepatitis B, and blood containing the
virus is destroyed without being used. (Note: you cannot get
hepatitis B by giving blood -- only by receiving it.)
However, hepatitis B can also be transmitted by other body fluids, and
in particular by sexual contact.

Hepatitis B infections typically start from 2 to 5 months after exposure to
the virus, and can produce mild symptoms in some people -- in fact, about
half of adults, and most children, infected with hepatitis B may have no
symptoms. The symptoms may include nausea and vomiting, loss of appetite,
fever, headache and muscle aches, tiredness, and abdominal pain (often above
and to the right of the umbilicus (the "belly button"); they may come on very
gradually rather than suddenly. Jaundice, if it occurs, starts 1 or 2 days
after the other symptoms appear and lasts for 1 to 3 weeks. Most of the
symptoms disappear along with the jaundice, but malaise and tiredness may
last for months.

Most people infected with hepatitis B recover completely: their immune
systems get rid of all the virus in the body, and they are immune to the
virus for the rest of their lives. However, about 1 in 50-100 infected adults
develop severe or "fulminant" hepatitis B infections, and up to 9 out of 10
people with fulminant hepatitis die of the disease. 1 out of 5 people cannot
fight off the infections completely: they become "chronic carriers" of the
virus and can later develop liver cancer due to damage from the virus.

The original hepatitis B vaccines were produced using blood from people
who had hepatitis B in the past. Today's vaccines are made using recombinant
DNA techniques, using brewers' yeast as the base cells for production,
and contain no human or animal blood products. The vaccine
gives immunity no matter how old you are; many pediatricians give the first
dose to newborn babies before they leave the hospital with their mothers.
Some babies -- those whose mothers are carriers of the hepatitis B virus --
must have their first dose of hepatitis B vaccine within 12
hours of birth, along with a dose of hepatitis B immune globulin.
There have been cases in which babies whose mothers were hepatitis B
carriers and did not receive the vaccine and immune globulin died from
hepatitis B infection. Because of this, some states (Michigan, where I
practice, is one) provide hepatitis B vaccine for all newborns and supply
hospitals with the vaccine so that every newborn can receive the first dose
of vaccine before going home after birth.

You need to have three doses of the vaccine for complete protection from
hepatitis B: the second dose is usually given 1-2 months after the first
dose, while the third is given 6-12 months after the first. These intervals
between doses are not absolutely necessary -- except for babies of hepatitis
B carriers, who must receive their second and third doses on time --
but the second dose has to be given no sooner than 1 month after the first
dose, and the third dose must be given at least 2 months after the second
(and at least 6 months after the first) dose. Just to confuse people more...
one of the two hepatitis B vaccines on the market can be given at birth,
1 month, and 2 months -- but if the third dose is given at 2 months the
patient has to receive a fourth dose at age 18 months. I do not know
of any pediatricians who use this schedule, except for children who are very
likely to be exposed to hepatitis B; even children of hepatitis B carriers
can receive three doses of vaccine if it is done on the recommended
"0 month-1 month-6 month" schedule. There is also a two-dose schedule
for one of the two vaccines that is being used in 11- to 15-year old children.

There are two situations in which hepatitis B vaccine should be given before
age 6 months.

If the baby's mother is a hepatitis B carrier, or if we do not know for
certain whether the mother is a carrier, then the baby must
receive hepatitis B vaccine (either RecombivaxTM
or EngerixTM) within 12 hours
after being born, because these babies are at risk of being
infected. (Babies whose mothers are proven to be hepatitis carriers
should also receive hepatitis B immune globulin in the first 12 hours.)
These babies should also get their second and third doses of vaccine
at ages 1 and 6 months.

If your doctor gives COMVAXTM (a combination
of hepatitis B and
Hemophilus influenzae (HIB) vaccines), the second dose may be
given at age 2 months. Since the HIB vaccine does not work well until 2
months or age, COMVAX should not be given before 2 months. The first dose
can be either RecombivaxTM or
EngerixTM, and should still be given at
birth.

And to make matters even more confusing, the rules are a bit different for
premature babies. Premies born to mothers who are known hepatitis B carriers
should still receive the vaccine immediately after birth. However, they
should receive another three doses, starting at 1 month of age.
Premies whose moms are hepatitis B negative may wait until they are a month
old to get their first dose of vaccine. The best advice I can give, as
always: ask your baby's doctor when to give the vaccine.

Infection with hepatitis C has exactly the same symptoms and signs as do hepatitis
A or B infections. Most hepatitis C infections tend not to have any symptoms, and
those symptoms that are seen are often mild and insidious (they come on very gradually).
Like hepatitis B, hepatitis C is spread by body-fluid contact; most people with
hepatitis C received blood from infected donors or are drug abusers. The risk of
getting hepatitis C from sexual contact is lower than it is with hepatitis B, but
it still happens. Like hepatitis B, hepatitis C can lead to liver cirrhosis
(breakdown of liver tissue -- cirrhosis occurs most famously in alcoholics, but
can also happen with viral hepatitis) and/or to liver cancer.

Unfortunately, there is no vaccine yet for hepatitis C, nor is there an immune
globulin to provide passive immunity. Treatment with interferon and ribavirin
can help some adults with hepatitis C, and may be useful in children as well.

Hepatitis D can be thought of as an incomplete virus: it needs help from the
hepatitis B virus in order to cause liver infection. However, simultaneous
infection with the two viruses may cause more severe disease than does hepatitis
B by itself: the hepatitis D virus can turn a mild chronic hepatitis B infection
into a much more severe infection. There is no specific treatment yet for
hepatitis D, but since hepatitis D cannot infect someone who does not have
hepatitis B we can prevent hepatitis D infection by immunizing against hepatitis B.

Hepatitis E, like hepatitis A, is passed from person to person by fecal-oral
contact. Hepatitis E has most often been seen in epidemics in parts of Mexico,
Asia, and Africa; it is occasionally seen in the United States, but usually in
people who have travelled to places where hepatitis E is common. Hepatitis E
is seen much more often in adults than in children, and pregnant women are
particularly likely to die of hepatitis E infection. There is no specific
treatment other than supportive care. The best way to prevent hepatitis E
infection is good hygiene and avoiding food or water which may be contaminated.

PLEASE NOTE: As with all of this Web site, I try to give
general answers to common questions my patients and their parents ask me
in my (real) office. If you have specific questions about your
child you must ask your child's regular doctor. No doctor can give
completely accurate advice about a particular child without knowing and
examining that child. I will be happy to try and answer
general questions
about children's health, but unless your child is a regular patient of
mine I cannot give you specific advice.